March 17, 2012 (San Diego, California) &#8212; Regardless of the fate of the Affordable Care Act, physicians in general, and dermatologists in particular, will be targeted as healthcare reform proceeds, Jack Resneck Jr., MD, told a packed audience here at the American Academy of Dermatology 70th Annual Meeting.

"Whatever you think about the Affordable Care Act...dermatology will be a target in the next few years," said Dr. Resneck, who has joint appointments as associate professor of clinical dermatology at the University of California at San Francisco and the San Francisco Institute for Health Policy Studies.

Dermatologists account for just 1% of physicians in the United States but 3.5% of Medicare expenditures, so they face growing attention from policy makers, he said.

"With the skin cancer epidemic, there may be incredibly good reasons for this, but it puts us on the radar screen."

The attention has led to "a perception problem in the eyes of other physicians who...probably don't have realistic ideas about what most of us actually do in our practices on a daily basis," he said.

Skin cancer is now the sixteenth mostly costly Medicare diagnosis, accounting for $2.9 billion annually. This is almost half of the $6.8 billion spent on cardiology. The rate of growth of some procedures, such as Mohs surgery, has increased by 400% over the past 15 years, said Dr. Resneck.

"This may be entirely justified [because] we have a massive skin cancer epidemic...[but] it gets people's attention in policy circles on the hill and at Medicare, and they tend to come after you."

As a result, the Relative Value Update Committee (RUC) has been assigned to review, among other dermatology codes, Mohs codes, pathology codes, and actinic keratosis codes in the next year. "And we know what happens when codes go to RUC &#8212; they do not get increased.... If you happen to be surveyed on how much work you do for these codes, do not ignore those surveys," he said.

Additionally, "we have seen other specialties coming after us in new ways over the past couple of years," he said. The College of American Pathologists has "even gone so far as to suggest to the deficit super committee that they can save money by not allowing dermatologists to read their own slides.... This is just a sign of things to come."

It is not just dermatology but medicine in general that is "in trouble in terms of figuring out how to fund what we do in years to come," said Dr. Resneck.
Although this pressure is largely due to the federal budget deficit, there is also pressure from business over the amount it is having to pay insurance companies. Private insurance has become unmanageable for many low-income employers such as Walmart or Target, which face employee health-insurance premiums that exceed the amount they pay in salaries, he said.
Tax revenue and discretionary spending are currently garnering the most attention, and blame, but future projections show that Medicare and healthcare spending are on the trajectory to become the overwhelming driver in spending growth. "This is not a sustainable course; and it makes the Social Security crisis look very meager," he said.

Dermatologists "have to take some responsibility for figuring out where savings are going to come from, "because if we keep sticking our heads in the sand, as we have tended to do in the past, somebody else is going to reshape the system without our input," Dr. Resneck explained.
Dr. Resneck has disclosed no relevant financial relationships.
American Academy of Dermatology (AAD) 70th Annual Meeting: Presented March 16, 2012.

Time to protect our field. If we let the slippery slope slide, badness is surely to ensue. For some years, many in derm have been cushioned by cash-only procedures, etc. With the blossoming of health spas and encroachment by other fields/practitioners, that time and comfort is endangered. It is now more than ever that we start protecting what is ours and justify what we actually do. If some of our fellow physicians find us to be no more than botox injectors, what can we expect from government officials?

Time to protect our field. If we let the slippery slope slide, badness is surely to ensue. For some years, many in derm have been cushioned by cash-only procedures, etc. With the blossoming of health spas and encroachment by other fields/practitioners, that time and comfort is endangered. It is now more than ever that we start protecting what is ours and justify what we actually do. If some of our fellow physicians find us to be no more than botox injectors, what can we expect from government officials?

Click to expand...

When you have academic allopathic dermatology residency programs that actively hire Nurse Practioners (who practice independently) and PAs (where a physician doesn't have to even be in the room, just in vicinity) on faculty, then we really shouldn't be surprised. This along with our inability, as physicians, to actively lobby unlike other healthcare groups, this should not be a huge surprise.

When you have academic allopathic dermatology residency programs that actively hire Nurse Practioners (who practice independently) and PAs (where a physician doesn't have to even be in the room, just in vicinity) on faculty, then we really shouldn't be surprised. This along with our inability, as physicians, to actively lobby unlike other healthcare groups, this should not be a huge surprise.

For me, this is one of the things that have bothered me the most. I did not match in derm, and absolutely love the field, and have been told that I would be a fantastic dermatologist by most attendings I've worked with, but I guess my numbers are not derm worthy. However, I find it mind blowing that the field would rather have PA's basically be dermatologists than have their own peers (other MDs) be dermatologists in order to keep their residency numbers down! It's absolutely mind blowing. At the last place I rotated, there were 3! PA's who saw patients independently for the most part. One of the PA's even said to one of the attendings, "You can't drive us out-we are here to stay." I was like wow, no kidding!

I kept thinking to myself, why would they prefer to have PA's see their patients vs. having 1-2 more spots and have fellow MD's actually become dermatologists? I personally don't understand it. Most patients would never know the difference, particularly given that a great majority of derm problems are easily treated by PA's/NP's. By keeping numbers so low and refusing to increase residency numbers to a more reasonable degree, derm is being overflown by midlevels. Oh well.

For me, this is one of the things that have bothered me the most. I did not match in derm, and absolutely love the field, and have been told that I would be a fantastic dermatologist by most attendings I've worked with, but I guess my numbers are not derm worthy. However, I find it mind blowing that the field would rather have PA's basically be dermatologists than have their own peers (other MDs) be dermatologists in order to keep their residency numbers down! It's absolutely mind blowing. At the last place I rotated, there were 3! PA's who saw patients independently for the most part. One of the PA's even said to one of the attendings, "You can't drive us out-we are here to stay." I was like wow, no kidding!

I kept thinking to myself, why would they prefer to have PA's see their patients vs. having 1-2 more spots and have fellow MD's actually become dermatologists? I personally don't understand it. Most patients would never know the difference, particularly given that a great majority of derm problems are easily treated by PA's/NP's. By keeping numbers so low and refusing to increase residency numbers to a more reasonable degree, derm is being overflown by midlevels. Oh well.

Click to expand...

Unfortunately, I guess the thing is that by keeping midlevels, most of the time, they contribute to the bottom line of a physician practice. The question is whether these midlevels will be able to see patients on their own w/out paying a "commission" to the MD.

Unfortunately, I guess the thing is that by keeping midlevels, most of the time, they contribute to the bottom line of a physician practice. The question is whether these midlevels will be able to see patients on their own w/out paying a "commission" to the MD.

Click to expand...

Sadly, I don't think that most midlevels really are doing much to keep the field alive. Just like in anesthesia, they are gaining ground, and now even have their own cosmetic practices as well. I don't think it will be long before they are able to independently see patients. In reality, most midlevels see patients on their own now with little to no MD involvement. When a field says well a nurse can do the same job I do for a lot less, you are in trouble. Look at what's happening in anesthesia.

The PA"s and NP's I've seen in academic derm offices have mainly been allowed to see wound care, routine skin checks, med checks, and other very very basic and mundane dermatology. Anything that makes even 1 hair stand on end requires a real dermatologist. Maybe this is just what I've observed?

The PA"s and NP's I've seen in academic derm offices have mainly been allowed to see wound care, routine skin checks, med checks, and other very very basic and mundane dermatology. Anything that makes even 1 hair stand on end requires a real dermatologist. Maybe this is just what I've observed?

Click to expand...

That has been my experience as well.

Out of all the academic programs I've seen (med school home dept, 2 away rotations, intern year derm rotation, and my current residency program) only one place employed any midlevels. In that case, the PA only saw routine postop wound checks in the Mohs clinic, a task which I consider to be appropriate for midlevels.

Sadly, I don't think that most midlevels really are doing much to keep the field alive. Just like in anesthesia, they are gaining ground, and now even have their own cosmetic practices as well. I don't think it will be long before they are able to independently see patients. In reality, most midlevels see patients on their own now with little to no MD involvement. When a field says well a nurse can do the same job I do for a lot less, you are in trouble. Look at what's happening in anesthesia.

Click to expand...

I don't think that issue is unique to dermatology and anesthesia. Almost any field that involves clinic has room for midlevel encroachment on basic, "bread & butter" type cases.

That said, in all honestly, I'm not sure ANY physicians need to lose sleep over being "replaced" by midlevels. Based on the kinds of referrals we get from local private practice PAs/NPs, the knowledge deficit is pretty evident, especially when any case veers away from basic, primary-care level dermatology (for example, referral for "AKs not responding to Efudex," when in reality patient has obvious immunobullous disease).

"It's going to be bad, bad. The best-case scenario our team has worked out is a 25% cut," Dr. Coldiron said at the Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF).
It's entirely possible that the committee will instead recommend closer to a 50% slash in its report to the Center for Medicare and Medicaid Services, added Dr. Coldiron, who has represented dermatology on the Relative Value Scale Update Committee (RUC) or served in an advisory capacity for the past 19 years.

When you have academic allopathic dermatology residency programs that actively hire Nurse Practioners (who practice independently) and PAs (where a physician doesn't have to even be in the room, just in vicinity) on faculty, then we really shouldn't be surprised. This along with our inability, as physicians, to actively lobby unlike other healthcare groups, this should not be a huge surprise.

As a resident at USF I should help clear up a misconception here on SDN. The dermatology nursing BS that's going on at USF has NOTHING to do with the Dermatology department. The college of nursing, obviously, is indepedent of our department. The DNP "program" that they started is completely through the nursing school. They work with a private dermatologist not affiliated at all with the Dermatology department. I can assure your our the chairman of our Dermatology Dept has actively campaigned against this program.

If you don't think this may happen at your institution your are wrong. All it takes is an aggressive nursing dean and these programs will start to crop up everywhere.

As a resident at USF I should help clear up a misconception here on SDN. The dermatology nursing BS that's going on at USF has NOTHING to do with the Dermatology department. The college of nursing, obviously, is indepedent of our department. The DNP "program" that they started is completely through the nursing school. They work with a private dermatologist not affiliated at all with the Dermatology department. I can assure your our the chairman of our Dermatology Dept has actively campaigned against this program.

If you don't think this may happen at your institution your are wrong. All it takes is an aggressive nursing dean and these programs will start to crop up everywhere.

Click to expand...

Wholeheartedly agree. Look at what's happening with anesthesia with CRNAs. It will definitely lead to trouble for derm. And when you have dermatologists joining up with the nursing program, whether affiliated with the department or not, to create derm residencies for nurses/NPs/PAs whatever it will lead to a gloominess in the future. For most patients too, they have no idea about the difference between healthcare professionals-they just want to see someone. As I mentioned before, at the last program I rotated there were several PAs who practiced practically independently, and had a much shorter wait time than the dermatologists, and even some patients were transferring to them given the shorter wait times.

Also in FM/IM, etc NP/PA are gaining ground, and many people see them with no issue. The propagation of these programs will without fail hurt the field.

As a resident at USF I should help clear up a misconception here on SDN. The dermatology nursing BS that's going on at USF has NOTHING to do with the Dermatology department. The college of nursing, obviously, is indepedent of our department. The DNP "program" that they started is completely through the nursing school. They work with a private dermatologist not affiliated at all with the Dermatology department. I can assure your our the chairman of our Dermatology Dept has actively campaigned against this program.

If you don't think this may happen at your institution your are wrong. All it takes is an aggressive nursing dean and these programs will start to crop up everywhere.

No, not true. If you see the third link (the one with Page 11 next to it), you'll see the newsletter is from Spring 2012. Due to the previous outcry, they have taken it off their website if you click the original link from that thread, but it still exists.

The PA"s and NP's I've seen in academic derm offices have mainly been allowed to see wound care, routine skin checks, med checks, and other very very basic and mundane dermatology. Anything that makes even 1 hair stand on end requires a real dermatologist. Maybe this is just what I've observed?

Click to expand...

I can only speak to my experience, but it has definitely gone beyond wound care, routine skin checks, med checks, and "basic and mundane dermatology".

As you can see here from this hilarious interview (on Fox and Friends, no less): http://video.foxnews.com/v/4161870/the-nurse-will-see-you-now/
As you can see from 2:23 to the end, you'll see that NPs (or I'm sorry, DNPs, as they would have a Doctorate in Nursing Practice), don't just want to be limited to do the mundane and basic.

In addition to primary care, the most likely fields for NP's to target are EM and derm.

You put a bullseye on your specialty when your field is high paying, low litigation risk, and good hours (no nights/weekends, holidays). Since most NP's are women, it is logical for them to want to do derm.

Derm will need to increase their ranks to decrease the patient demand. Otherwise, NP's will fill that demand for you. Either way, it's not good for the profession. Most likely, the existing derm leadership will keep the status quo so that the old timers can make their money now while screwing future derms in the process. That's what happened in anesthesiology. No true leadership or courage to avert the train wreck that will befall the specialty in the future.

In addition to primary care, the most likely fields for NP's to target are EM and derm.

You put a bullseye on your specialty when your field is high paying, low litigation risk, and good hours (no nights/weekends, holidays). Since most NP's are women, it is logical for them to want to do derm.

Derm will need to increase their ranks to decrease the patient demand. Otherwise, NP's will fill that demand for you. Either way, it's not good for the profession. Most likely, the existing derm leadership will keep the status quo so that the old timers can make their money now while screwing future derms in the process. That's what happened in anesthesiology. No true leadership or courage to avert the train wreck that will befall the specialty in the future.

Click to expand...

This is precisely what I have said! And if a medical field is so narrow sighted to prefer to have a midlevel vs a fellow physician to fill one of their positions, then that's on them! No one will feel bad for dermatologists either. Derm will not increase residency positions bullheadedly, and NP's in particular will be at the gates waiting to fill the demand. Patients just want to be seen, they don't care by whom really.

And let's face it-the vast majority of dermatology seen in clinics is not rocket science, and is simple enough to be done by midlevels. Also, so many dermatologists have degenerated the profession so much it's sad! I have heard people in leadership positions in training programs talk about how they hate dermatology, and only do "cosmetics," and attendings in major medical centers talk about how they have no interest in treating medical dermatology. Truly sad.

This is precisely what I have said! And if a medical field is so narrow sighted to prefer to have a midlevel vs a fellow physician to fill one of their positions, then that's on them! No one will feel bad for dermatologists either. Derm will not increase residency positions bullheadedly, and NP's in particular will be at the gates waiting to fill the demand. Patients just want to be seen, they don't care by whom really.

And let's face it-the vast majority of dermatology seen in clinics is not rocket science, and is simple enough to be done by midlevels. Also, so many dermatologists have degenerated the profession so much it's sad! I have heard people in leadership positions in training programs talk about how they hate dermatology, and only do "cosmetics," and attendings in major medical centers talk about how they have no interest in treating medical dermatology. Truly sad.

Click to expand...

I've been told that 40 years ago no one wanted to do derm. Then, I guess with procedures and cosmetics it shot up in popularity.

As people realize that it is being infiltrated by NP's, reimbursements go down, job prospects more difficult, you'll see a decline in interest.

I don't think cosmetics is a savior for derm either. It's unregulated, takes a lot of capital and overhead, and practically anyone can do it.

This is precisely what I have said! And if a medical field is so narrow sighted to prefer to have a midlevel vs a fellow physician to fill one of their positions, then that's on them! No one will feel bad for dermatologists either. Derm will not increase residency positions bullheadedly, and NP's in particular will be at the gates waiting to fill the demand. Patients just want to be seen, they don't care by whom really.

And let's face it-the vast majority of dermatology seen in clinics is not rocket science, and is simple enough to be done by midlevels. Also, so many dermatologists have degenerated the profession so much it's sad! I have heard people in leadership positions in training programs talk about how they hate dermatology, and only do "cosmetics," and attendings in major medical centers talk about how they have no interest in treating medical dermatology. Truly sad.

Click to expand...

Besides reeking of sour grapes, I would caution you to not speak so boldly about things you have limited experience with. I am not sure which programs you have rotated through as a medical student, but I can assure you (and I suspect the bulk of my peers would agree) that your bolded comments are not the prevailing sentiment among most dermatologists (private or academic), midlevel-providers, and patients

Besides reeking of sour grapes, I would caution you to not speak so boldly about things you have limited experience with. I am not sure which programs you have rotated through as a medical student, but I can assure you (and I suspect the bulk of my peers would agree) that your bolded comments are not the prevailing sentiment among most dermatologists (private or academic), midlevel-providers, and patients

Click to expand...

No sour grapes here. Reality is reality. Are we stating that derm is now rocket science? Why would it be that NP/PA are able to practice side by side with derm residents? And I've rotated not just as a med student but as an intern as well, and all programs have had PA's and they have all practiced pretty much independently. And trust me, these were major academic centers, no podunk derm clinics in the middle of nowhere. Further, while some high end centers may see very complex cases, most places don't, and it's the reason why most midlevels can see a great % of the cases dermatologists see.

You can argue otherwise, but why do you see such a huge concern in the academic derm community with the lack of people going into academic derm? Everyone wants to do cosmetics immediately after derm. at 90% of the places I've interviewed, this is a concern many faculty members have voiced. Are we really denying this now?

I've been told that 40 years ago no one wanted to do derm. Then, I guess with procedures and cosmetics it shot up in popularity.

As people realize that it is being infiltrated by NP's, reimbursements go down, job prospects more difficult, you'll see a decline in interest.

I don't think cosmetics is a savior for derm either. It's unregulated, takes a lot of capital and overhead, and practically anyone can do it.

Click to expand...

Absolutely agree with you. Unfortunately dermatologists will argue otherwise, I think that's the case asmallchild is also arguing, but it's the truth. Most people in derm go into derm not because they love the field but bc they think it's a cash cow and go into cosmetics. One of the leading dermatologists that I rotated with even told me, well this is why the field is so competitive these days-bc of all the cosmetic procedures. Cosmetics is done by spas runned by IM/FP even OB/EM and now even chiropractors, and aestheticians themselves!

I think you are not accurate when you suggest most dermatology is easy. Midlevels can practice only when there are physicians available to take the tough cases off their hands. It is the same for ALL medical fields. Midlevels can practice because they know that when their treatment fails they can go ask the physician what to do.

And let's face it-the vast majority of ambulatory medicine is not rocket science...

Click to expand...

Went ahead and fixed that for you.

Outside of tertiary care/referral centers, the majority of outpatient clinic based medicine, across virtually all specialties, falls into a rut of repeatedly diagnosing and treating a handful of routine conditions. This is not unique to dermatology. The only medical fields that are relatively safe from any midlevel encroachment are the surgical specialties, radiology, and path. Even in those cases, who's to say you can't eventually train an NP to do a lap-appy? One of the PAs on this forum posted some nonsensical study out of Duke showing that PAs performing cardiac caths (in a carefully selected subset of patients) had similar outcomes to cards fellows. I guess that's not rocket science either.

The problem is that patients don't read the textbook before presenting to clinic; complex medical issues show up in private practices too. I stand by my original statement. Midlevels do a reasonable job of managing typical presentations of routine problems. The minute anything veers off the expected path (whether is an uncommon condition, or simply an atypical presentation of a common problem) they flounder.

I've been told that 40 years ago no one wanted to do derm. Then, I guess with procedures and cosmetics it shot up in popularity.

Click to expand...

I have a hard time believing that. Forty years ago, IMGs were flooding Amrican GME programs across virtually all specialties (comprising about 1/3 of all residents). However, even back then, they weren't getting into dermatology, making up only about 8% of derm residents.

actually, all surgery is being encroached upon by robotic surgery and medical tourism. There are no sacred cows. At the end of the day, the only thing physicians have that no one else has is the ability to think on their feet when things go wrong/don't fit the textbook. I just think it is silly to think that anything else is inherently better when a physician does it. I want a physician doing my procedure because I want the peace of mind that if something goes wrong, he can fix it. When things go right, of course there will be no difference. I also would prefer an NP for all my preventative medicine because a physician is overkill. The real physicians on the chopping block are those in primary care, in my opinion.

no, i mean non-americans doing the surgery on american patients here in the states. I mean isn't the point the future of american docs? They want to have a surgeon in india and a nurse in america with a video feed and the foreign doc controlling the davinci from afar. sorry if I was unclear.

To compound the problem, certain individuals, once in residency, are no longer motivated to work extended hours. This may be for family or lifestyle reasons.

The solution is to maintain oversight and train as many PAs as your state allows. Do not get complacent and decide to work your 30 hours a week without being involved in teaching (residents/PAs). Understand the legalities and stay knowledgeable of the political process. As physicians, we have a tendency to take what they give us. Congress, on the other hand, gets to trade on priviledged information.

To my co-residents: if you chose to work fewer hours, please consider a part-time teaching position, or train PAs that will stay with you. Clinical instructors are difficult to come by, and that is the source of so few dermatology programs.

To the academic programs: please consider providing a salary based on production, and make it a reasonable one, so attendings don't have to take a 50% cut to teach.

Also, explain to patients that their insurance does not cover treating everything in one visit. Learn to code and document appropriately. Learn to be efficient. If your patient wants a running subcuticular vs running simple, and it takes you an extra few minutes, you may need to explain to them that the insurance doesn't cover it and that you would need to charge more (although I don't know if that is even legal).

Consider going to a cash based practice, and let the patients submit their own paperwork. A lot of dentristry is that way.

What most all other specialties and the government don't realize is that the spending in dermatology has a greater impact on quality of life, and on increasing productive years per dollar spent, than most other specialties. I'll give two examples:
1. I do 500 skin screenings, and catch one 30 y.o. professional with a superficial spreading melanoma, caught at 0.6mm. Wide local excision-->cured.
2. 80 y.o. with BCC of the nasal tip: patient is homeridden, too embarassed to leave the house. As a result, quality of life is poor. Mohs+bilobed flap-->patient now can have a normal quality of life.

Here goes my rant.
The whole healthcare reimbursement is a big sham. Politicians issue debt to pay for whoever votes for them, in this case, the elderly. They are retired, and stay active in political issues, and so they hear so and so will get their healthcare payed for, and they go and vote. Then they retire at 65, and live for 30+ years, and consume about 5 times what was originally planned for them.
It makes much more sense to pay for #1 from a value standpoint, because the patient will continue to be a productive member of society.
$50,000 to save 40 patient years (with the additional ease of mind for the other 499 people) So Cost $1250/year, probably much less than that group of individuals pays into the system in taxes.
People with #2 have a much much shorter expected time for additionally contributing, so those services should only be covered in as much as those people paid into the system.

I'll start by stating that I plan on doing a Mohs or procedural fellowship.

The solution is to align incentives with what is best for society. I'm all for medicare not covering Mohs or fancy flaps. Thats ok, because anyone with $2K extra will pay me to do it, and I will take the time necessary to do the best job.
But I do think that if we are interested in doing the best for our country, then we should spend the resources where we get the most return. So bye bye dialysis centers for people on disability, bye bye extended living facilities for people who are terminally ill, and bye bye tretinoin for old ladies unhappy with their wrinkles. Hospice it is.

Who here would work for just enough to live a minimal quality of life? Nobody. I spent a portion of my twenties with no income, thousands of hours in the libary, healing the sick, and researching. I deserve to be paid on the same level as other professionals. I also deserve the fair market rate, and not to be monopolized against by a universal payer. We all became physicians to help people, with the expectation that we would be able to afford a good quality of life for ourselves and our family.

Intelligent professionals with 4 years of post graduate training at the top of their field, for the most part, make 6-7 figures. We are the cream of the crop. Their is one new resident per MILLION in the US. We are not the dermatologists that graduated 40 years ago, when no one else wanted to enter this field. This is the hardest specialty to match into, and when no one else knows what to do for a condition, guess who they consult. We read more than all other fields. We have to master pathology, surgery, pediatrics, (oh and general derm too).

Don't worry about how other specialists perceive you, because when they are calling you about their patient with their skin is falling off, or who has purulent ulcers on their lower extremities, or who is febrile with a new facial eruption after starting their neupogen, they will never again undervalue you. The impression of dermatology will change with time. Most who talk down about derm are haters (i.e. they didn't understand themselves well enough to make the right choice for themselves). Most of the specialists who I've interacted with in a more personal setting (anesthesiologists, internal medicine, surgery, etc are always impressed that I chose dermatology).

And don't forget, patients LOVE their derms. Even as a resident, patients want to see the "doctor" and usually are upset until I've turned them around and shown how much I know and care about their reason for being in the hospital. We matched because we are smart, hardworking, and have amazing personalities. Most other fields are pretty grumpy.

This is how I predict things will go down:
More and more NPs/PAs will enter derm.
Over time, "horror" stories of how the NP missed/misdiagnosed a melanoma, sent someone into hepatic/renal failure, gave a kid glaucoma with topicals, etc, will increase.
Legislation will restrict NPs to using topicals (retinoids/antibacterials/midpotency and lower), otherwise they will require physcian oversight.
Anything but the simple stuff will be turfed to us.

GET INVOLVED POLITICALLY. BE VOCAL TO YOUR PATIENTS ABOUT THE CHANGES HAPPENING. THEY WILL BE ON YOUR SIDE.

To compound the problem, certain individuals, once in residency, are no longer motivated to work extended hours. This may be for family or lifestyle reasons.

The solution is to maintain oversight and train as many PAs as your state allows. Do not get complacent and decide to work your 30 hours a week without being involved in teaching (residents/PAs). Understand the legalities and stay knowledgeable of the political process. As physicians, we have a tendency to take what they give us. Congress, on the other hand, gets to trade on priviledged information.

To my co-residents: if you chose to work fewer hours, please consider a part-time teaching position, or train PAs that will stay with you. Clinical instructors are difficult to come by, and that is the source of so few dermatology programs.

To the academic programs: please consider providing a salary based on production, and make it a reasonable one, so attendings don't have to take a 50% cut to teach.

Also, explain to patients that their insurance does not cover treating everything in one visit. Learn to code and document appropriately. Learn to be efficient. If your patient wants a running subcuticular vs running simple, and it takes you an extra few minutes, you may need to explain to them that the insurance doesn't cover it and that you would need to charge more (although I don't know if that is even legal).

Consider going to a cash based practice, and let the patients submit their own paperwork. A lot of dentristry is that way.

What most all other specialties and the government don't realize is that the spending in dermatology has a greater impact on quality of life, and on increasing productive years per dollar spent, than most other specialties. I'll give two examples:
1. I do 500 skin screenings, and catch one 30 y.o. professional with a superficial spreading melanoma, caught at 0.6mm. Wide local excision-->cured.
2. 80 y.o. with BCC of the nasal tip: patient is homeridden, too embarassed to leave the house. As a result, quality of life is poor. Mohs+bilobed flap-->patient now can have a normal quality of life.

Here goes my rant.
The whole healthcare reimbursement is a big sham. Politicians issue debt to pay for whoever votes for them, in this case, the elderly. They are retired, and stay active in political issues, and so they hear so and so will get their healthcare payed for, and they go and vote. Then they retire at 65, and live for 30+ years, and consume about 5 times what was originally planned for them.
It makes much more sense to pay for #1 from a value standpoint, because the patient will continue to be a productive member of society.
$50,000 to save 40 patient years (with the additional ease of mind for the other 499 people) So Cost $1250/year, probably much less than that group of individuals pays into the system in taxes.
People with #2 have a much much shorter expected time for additionally contributing, so those services should only be covered in as much as those people paid into the system.

I'll start by stating that I plan on doing a Mohs or procedural fellowship.

The solution is to align incentives with what is best for society. I'm all for medicare not covering Mohs or fancy flaps. Thats ok, because anyone with $2K extra will pay me to do it, and I will take the time necessary to do the best job.
But I do think that if we are interested in doing the best for our country, then we should spend the resources where we get the most return. So bye bye dialysis centers for people on disability, bye bye extended living facilities for people who are terminally ill, and bye bye tretinoin for old ladies unhappy with their wrinkles. Hospice it is.

Who here would work for just enough to live a minimal quality of life? Nobody. I spent a portion of my twenties with no income, thousands of hours in the libary, healing the sick, and researching. I deserve to be paid on the same level as other professionals. I also deserve the fair market rate, and not to be monopolized against by a universal payer. We all became physicians to help people, with the expectation that we would be able to afford a good quality of life for ourselves and our family.

Intelligent professionals with 4 years of post graduate training at the top of their field, for the most part, make 6-7 figures. We are the cream of the crop. Their is one new resident per MILLION in the US. We are not the dermatologists that graduated 40 years ago, when no one else wanted to enter this field. This is the hardest specialty to match into, and when no one else knows what to do for a condition, guess who they consult. We read more than all other fields. We have to master pathology, surgery, pediatrics, (oh and general derm too).

Don't worry about how other specialists perceive you, because when they are calling you about their patient with their skin is falling off, or who has purulent ulcers on their lower extremities, or who is febrile with a new facial eruption after starting their neupogen, they will never again undervalue you. The impression of dermatology will change with time. Most who talk down about derm are haters (i.e. they didn't understand themselves well enough to make the right choice for themselves). Most of the specialists who I've interacted with in a more personal setting (anesthesiologists, internal medicine, surgery, etc are always impressed that I chose dermatology).

And don't forget, patients LOVE their derms. Even as a resident, patients want to see the "doctor" and usually are upset until I've turned them around and shown how much I know and care about their reason for being in the hospital. We matched because we are smart, hardworking, and have amazing personalities. Most other fields are pretty grumpy.

This is how I predict things will go down:
More and more NPs/PAs will enter derm.
Over time, "horror" stories of how the NP missed/misdiagnosed a melanoma, sent someone into hepatic/renal failure, gave a kid glaucoma with topicals, etc, will increase.
Legislation will restrict NPs to using topicals (retinoids/antibacterials/midpotency and lower), otherwise they will require physcian oversight.
Anything but the simple stuff will be turfed to us.

GET INVOLVED POLITICALLY. BE VOCAL TO YOUR PATIENTS ABOUT THE CHANGES HAPPENING. THEY WILL BE ON YOUR SIDE.

no, i mean non-americans doing the surgery on american patients here in the states. I mean isn't the point the future of american docs? They want to have a surgeon in india and a nurse in america with a video feed and the foreign doc controlling the davinci from afar. sorry if I was unclear.

Click to expand...

That's never going to happen.

That Indian surgeon can't operate on an American patient in the US without an American medical license. Not to mention the liability issues - if something goes wrong, who are the patients going to sue?

skinceutical, PM me about where you are a resident. I am intrigued where you are that you feel so vulnerable to other healthcare workers. Are you a derm resident in the USA?

Click to expand...

Yes, I am a resident in the US.

Where did you get the impression that I feel "so vulnerable" to midlevels? I've simply been arguing against the idea that derm has somehow set itself up for a midlevel takeover by pointing out that there's plenty of room for midlevel encroachment in virtually all clinical fields.

However, even in my first post on the issue in this thread, I pointed out "I'm not sure ANY physicians need to lose sleep over being "replaced" by midlevels... the knowledge deficit is pretty evident"

The only medical fields that are relatively safe from any midlevel encroachment are the surgical specialties, radiology, and path. Even in those cases, who's to say you can't eventually train an NP to do a lap-appy

Click to expand...

I agree with Skinceutical's overall assessment, both of derm and in general. As someone going into rads, I can say that despite lack of midlevel encroachment, we have considerable encroachment by vascular and cards, which is much worse. As far as the hospital admin is concerned, Cardiology is the single most important department in the hospital so interventional cards has enough clout to steal a market that was created (through innovation) by rads.

In a sense, the turf war in derm with midlevels is analogous, since the "bottom line" is the most important factor in decision-making at the hospital admin level. The cost savings gives the midlevels incredible leverage and allows them to sharpen their derm skills...in effect serving as a "derm residency" for them. The bottom line is that practice makes perfect in medicine and if midlevels are given more opportunities, they will eventually rival MDs. They may even successfully lobby for surgical privileges, like optometrists did in OK.

And let's face it-the vast majority of dermatology seen in clinics is not rocket science, and is simple enough to be done by midlevels.

Click to expand...

While I agree with most of your post, this one sentence shows why the encroachment by other specialties, primary care, midlevels, and non-healthcare places has taken place. When you say that certain diagnoses are easy enough to be done by others, then don't be surprised when it is allowed to happen, and those who do eventually start demanding to see more complex issues.

Unfortunately, I guess the thing is that by keeping midlevels, most of the time, they contribute to the bottom line of a physician practice. The question is whether these midlevels will be able to see patients on their own w/out paying a "commission" to the MD.

Click to expand...

That is actually what midlevels are organizing and fighting for on the state level, while the AMA and the AAD sit idly by. They want an autonomous & independent practice AND they want to charge the 100%, not just receive the 85%, that they currently receive.

Besides reeking of sour grapes, I would caution you to not speak so boldly about things you have limited experience with. I am not sure which programs you have rotated through as a medical student, but I can assure you (and I suspect the bulk of my peers would agree) that your bolded comments are not the prevailing sentiment among most dermatologists (private or academic), midlevel-providers, and patients

Click to expand...

Very well said, asmallchild. Hard to tell whether Dermpath just has sour grapes from not matching into Dermatology and thus got his jabs in, or just trolling as demonstrated by his/her statement, "I have heard people in leadership positions in training programs talk about how they hate dermatology, and only do "cosmetics," and attendings in major medical centers talk about how they have no interest in treating medical dermatology" ---- when if you actually meet program directors and chairmen/chairwomen of academic allopathic dermatology residency programs (many of whom go to the SID meeting, as well as the AAD meeting that everyone goes to) - nothing could be further than the truth.

No sour grapes here. Reality is reality. Are we stating that derm is now rocket science? Why would it be that NP/PA are able to practice side by side with derm residents? And I've rotated not just as a med student but as an intern as well, and all programs have had PA's and they have all practiced pretty much independently. And trust me, these were major academic centers, no podunk derm clinics in the middle of nowhere. Further, while some high end centers may see very complex cases, most places don't, and it's the reason why most midlevels can see a great % of the cases dermatologists see.

You can argue otherwise, but why do you see such a huge concern in the academic derm community with the lack of people going into academic derm? Everyone wants to do cosmetics immediately after derm. at 90% of the places I've interviewed, this is a concern many faculty members have voiced. Are we really denying this now?

Click to expand...

You have to be careful about overgeneralizing. Derm is not rocket science but neither is any medical field...I would know because I've done actual rocket science before...but it is a scientific art and not a simple art either. Derm encompasses so many fields that you really do need full medical training (DO or MD) to do it well. I can't tell you how many times the derm comes into the case on a crazy consult and gets the answer and this could happen in the inpatient or the outpatient setting. You need the medical training and the experience with the nuances of skin lesions that any midlevel couldn't do it. If I could have a nickel for all the times a patient came in with warts that was already "previously treated with freezing" that I then cleared with cryotherapy....it's not rocket science but you still have to do it right.

Sure, all dermatologists want to do some cosmetics but I highly doubt you will find anyone that only wants to do cosmetics. Besdies, it's a part of dermatology. Everyone can do derm if looks like the textbook but there are a lot of times that it doesn't. I would say 90% want to do some cosmetics but not all cosmetics as you imply. Most of my friends in derm like med derm and surgical derm too and want to a little bit of everything.

Finally it's not that you see complex cases all the time since most cases in any part of medicine are not complex but you see them often enough that the right training is essential.

Very well said, asmallchild. Hard to tell whether Dermpath just has sour grapes from not matching into Dermatology and thus got his jabs in, or just trolling as demonstrated by his/her statement, "I have heard people in leadership positions in training programs talk about how they hate dermatology, and only do "cosmetics," and attendings in major medical centers talk about how they have no interest in treating medical dermatology" ---- when if you actually meet program directors and chairmen/chairwomen of academic allopathic dermatology residency programs (many of whom go to the SID meeting, as well as the AAD meeting that everyone goes to) - nothing could be further than the truth.

Click to expand...

Umm, not sure why you are attacking me. I am telling you exactly what I have been told by certain people when I've rotated there, and the serious concerns from an academic perspective that few people want to do academics in derm, but rather go into cosmetics. I have also rotated at places where attendings in high places have told me that they hate gen. derm, and when I met with yet another attending at a different program this person told me he only does cosmetics and lasers. I also rotated with someone who is a gen derm and does exclusively cosmetics with several partners. The concern that few derm grads want to go into academic deerm is directly from the mouth of PD/division chairs, so unless you were rotating with me and/or in my interviews, I am not sure how you say otherwise?
I am sorry but the reason derm is so competitive is because it's good $$ for the work and because of the perceived impression that cosmetics can bring in big $$$.

Umm, not sure why you are attacking me. I am telling you exactly what I have been told by certain people when I've rotated there, and the serious concerns from an academic perspective that few people want to do academics in derm, but rather go into cosmetics. I have also rotated at places where attendings in high places have told me that they hate gen. derm, and when I met with yet another attending at a different program this person told me he only does cosmetics and lasers. I also rotated with someone who is a gen derm and does exclusively cosmetics with several partners. The concern that few derm grads want to go into academic deerm is directly from the mouth of PD/division chairs, so unless you were rotating with me and/or in my interviews, I am not sure how you say otherwise?
I am sorry but the reason derm is so competitive is because it's good $$ for the work and because of the perceived impression that cosmetics can bring in big $$$.

Click to expand...

I am sorry to hear you (dermpath) had such a bad bunch of experiences. I guess you really do have to pick the right residency. I would never go to a residency that openly disliked gen derm or felt cosmetics was the ultimate goal. Maybe you should consider that you may have misunderstood the attendings or caught them on a bad day. I certainly did not choose derm for the money and cosmetics, but "the percieved impression" you give is not necessarily the same for everyone. Maybe the attendings were testing you to uncover your true perceptions. Who knows. I am sure some derms love cosmetics but I think most derms like to mix it up and try a little of everything.

Training PAs and maintaining oversight is the solution. The PA works for you. A 2 month acne follow up for topical reitnoid+/-topical abx does not require an MD. A moderate atopic managed on topicals, does not need an MD.

Ultimately a PA needs to gain the confidence of the physician, otherwise patients will get hurt. Can you imagine a PA, straight out of school, out on his/her own, trying to figure out the difference between an SK and a compound nevus? How about between a junctional nevus and an MIS? No pigmented lesion will be safe. We will be a moleless country. They'll end up biopsing EVERYTHING. And then, thats gotta go to a dermpath (~90 new dermpaths/year), who certainly wont work for free. (And if you think dermpath is something PA/NPs can do, dream on unless they have a PhD in histology)

The alternative is for the AAD to create a PA/NP exam, or exams which would cover their expected competencies. One thing the government could do to provide a stipend to academic physicians who teach more.

So the solution is: Wake up. Derm is gonna involve seeing more complicated patients. You will still make bank for those cosmetic/non covered services, and you will be billing more level 4/5.

Any time an CTCL patient comes in, the PAs run away. We have an NP who is very hard working, but her notes read like novels and its clear that she's still trying to include everything instead of only relevant information. Do you think PAs want to worry about dosing bexarotene?

The thing that scares people is that they won't make 500K a year working 35 hours and freezing AKs, billing level 3s by choosing symptoms likely unrelated to the diagnosis, and documenting a complete skin exam. Sorry ladies, no more easy purse money. Sorry gents, you might get less time at the golf course/country club. No community derms want to deal with the "headache". Boo hoo. :'( You mean I cant just spend glance at a patient and make $1000/hr? Wake up and grow up. Really I'm just tired of hearing patients come and see us in academia because the private derms barely gave them the time of day.

Doesn't it make sense to put what distinguishes you, your MEDICAL EDUCATION, to good use?
Well, get comfortable with accutane/cellcept/soriatane/methotrexate/cyclosporine/pdt/facial anatomy/complex closures/etc.

If you care about money, or want to work less, your best bet is to learn to invest, learn to protect your assets, and live a thrifty lifestyle. Stop watching so much cable TV.

Training PAs and maintaining oversight is the solution. The PA works for you.
...
The alternative is for the AAD to create a PA/NP exam, or exams which would cover their expected competencies. One thing the government could do to provide a stipend to academic physicians who teach more.

Click to expand...

Yes, PAs currently work under some degree of physician oversight at this point in time. Once you formalize training and specialty certification (as you suggest), you're just going to have another group of noctors claiming equivalency and demanding independent practice rights.

What's the ultimate goal here? It sounds like you want to set up a two tiered system, akin to the ophtho/optometry set up. "Derm certified" midlevels will see the "basic" cases (and miss God knows what in the process) and we'll handle their referrals.

Training PAs and maintaining oversight is the solution. The PA works for you. A 2 month acne follow up for topical reitnoid+/-topical abx does not require an MD. A moderate atopic managed on topicals, does not need an MD.

Ultimately a PA needs to gain the confidence of the physician, otherwise patients will get hurt. Can you imagine a PA, straight out of school, out on his/her own, trying to figure out the difference between an SK and a compound nevus? How about between a junctional nevus and an MIS? No pigmented lesion will be safe. We will be a moleless country. They'll end up biopsing EVERYTHING. And then, thats gotta go to a dermpath (~90 new dermpaths/year), who certainly wont work for free. (And if you think dermpath is something PA/NPs can do, dream on unless they have a PhD in histology)

The alternative is for the AAD to create a PA/NP exam, or exams which would cover their expected competencies. One thing the government could do to provide a stipend to academic physicians who teach more.

So the solution is: Wake up. Derm is gonna involve seeing more complicated patients. You will still make bank for those cosmetic/non covered services, and you will be billing more level 4/5.

Any time an CTCL patient comes in, the PAs run away. We have an NP who is very hard working, but her notes read like novels and its clear that she's still trying to include everything instead of only relevant information. Do you think PAs want to worry about dosing bexarotene?

The thing that scares people is that they won't make 500K a year working 35 hours and freezing AKs, billing level 3s by choosing symptoms likely unrelated to the diagnosis, and documenting a complete skin exam. Sorry ladies, no more easy purse money. Sorry gents, you might get less time at the golf course/country club. No community derms want to deal with the "headache". Boo hoo. :'( You mean I cant just spend glance at a patient and make $1000/hr? Wake up and grow up. Really I'm just tired of hearing patients come and see us in academia because the private derms barely gave them the time of day.

Doesn't it make sense to put what distinguishes you, your MEDICAL EDUCATION, to good use?
Well, get comfortable with accutane/cellcept/soriatane/methotrexate/cyclosporine/pdt/facial anatomy/complex closures/etc.

If you care about money, or want to work less, your best bet is to learn to invest, learn to protect your assets, and live a thrifty lifestyle. Stop watching so much cable TV.

Click to expand...

Laxman,

Your post is awesome. I completely agree with the general sentiment of your post--a lot of people are attracted to Derm because of the cushy lifestyle and big bucks. I feel like it gets a lot of disengenous people because of the high pay and easy life. And I've hear the same thing before about community Derms not seeing more difficult cases--it interferes with them making more money faster (who cares about serving the community, right?) I feel like the sense of entitlement in medicine is at an all-time high, and the mentality of a lot of people going into derm right now seems to embody that pretty well: all I need to worry about is making money and I'm not going to work hard to do it.

The other thing is that Dermatology has become its own worst enemy: by keeping the numbers of graduating derms artifically low, there is enormous demand in the community for Derms. Wait times are, what, weeks bordering on months in many places? That's ridiculous. I'm not supprised that the NP/PA/DNP whatevers are coming in and getting a piece of the action. Granted, I don't support the midlevel business and the watering down of medical education, but I'm not the least bit suprised. Derms seem to be serving more of their own interests rather than serving the community, and at some point a group of people are going to step in and do something about it: witness the creation of DNP Derm residencies.

The solution IS midlevels, that we oversee and train, and that we bill for. Optimally the patient would always have access to the doctor, knowing that it would cost more to see them, Initial visits should always be staffed with the doc (IMHO) to establish rapport and provide a quick screening.

In the end, do you think a lawyer/physician/banker wants their botox/chemical peels/BCC/whatever treated by an NP? Nope.

Your post is awesome. I completely agree with the general sentiment of your post--a lot of people are attracted to Derm because of the cushy lifestyle and big bucks. I feel like it gets a lot of disengenous people because of the high pay and easy life. And I've hear the same thing before about community Derms not seeing more difficult cases--it interferes with them making more money faster (who cares about serving the community, right?) I feel like the sense of entitlement in medicine is at an all-time high, and the mentality of a lot of people going into derm right now seems to embody that pretty well: all I need to worry about is making money and I'm not going to work hard to do it.

The other thing is that Dermatology has become its own worst enemy: by keeping the numbers of graduating derms artifically low, there is enormous demand in the community for Derms. Wait times are, what, weeks bordering on months in many places? That's ridiculous. I'm not supprised that the NP/PA/DNP whatevers are coming in and getting a piece of the action. Granted, I don't support the midlevel business and the watering down of medical education, but I'm not the least bit suprised. Derms seem to be serving more of their own interests rather than serving the community, and at some point a group of people are going to step in and do something about it: witness the creation of DNP Derm residencies.

Click to expand...

Bingo!

I like to look at medicine like most things in life using the 80/20 rule - meaning that 80% of cases are routine. That's true for pretty much for all medical fields. It's that 20% that you really need a physician with all the training that is involved. So, if you're an NP who wants to work autonomously, your job is to separate the routine from the complex cases.

This is where primary care and derm get into trouble with NP's. Like primary care, most derm cases are non-emergent. So even if you misdiagnose something initially, you can follow the patient on short-term follow-up - say within one or two weeks. After one or two follow-up visits and your treatment plan isn't working, what do you do? Simple. Refer the patient to a real physician, in this case a dermatologist. Again like primary case, what does an NP do if she suspects if the patient appears in serious imminent trouble? Send the patient to the ED, where a dermatologist can be consulted.

The reason why a field like surgery is less at risk from NP's is because the NP does not have the luxury of time or margin for error. If the NP accidentally snips a vessel, the patient is dead within minutes. If the NP cuts a nerve, the patient is paralyzed permanently. Then it gets into the media and the politicians will crack down on it.

But I suspect that most NP's want to do derm for the same reason why most med students want to do it. It's not for medical derm. It's for cosmetics. Like I said before, cosmetics is unregulated and practically anyone with the appropriate healthcare license and enough money can go into it.

If they can open up a medical spa now, why do NP's want to start derm residencies? I suspect that it's to be able to introduce themselves as "doctor" and to legitimatize themselves by claiming that they are "a derm specialist" because they are "board-certified" by some stupid nursing organization which will no doubt be created to accredit these residencies.

As someone pointed out before, these derm residencies are not under the control of the GME but under the nursing programs. They will spring up like weeds nationwide because nursing in general wants to push itself onto as much of medical turf as possible and because it will be a big money maker for the nursing programs because they will charge these wannabe nursing derms a lot of tuition money. If students are naive enough to hand over $50k per year in tuition for law or pharmacy schools where the job prospects are horrendous, then I bet that these derm residencies will have no trouble getting applicants.

So, bottom line, the factors that drove up interest in derm from medical students will be the same ones that will turn people off from it in the future.